- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $53.70 / $56.23 / $56.23
| Facility | 26 | $53.70 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $100.00 / $213.80
| Professional | | $83.18 | $100.00 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $190.55 / $239.88
| Professional | | $181.97 | $190.55 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $151.36 / $588.84
| Professional | | $85.11 | $151.36 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $186.21 / $218.78
| Professional | | $181.97 | $186.21 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $107.15 / $128.82
| Professional | 26 | $100.00 | $107.15 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $181.97 / $218.78
| Professional | | $181.97 | $181.97 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $151.36 / $194.98
| Professional | | $104.71 | $151.36 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $60.26 / $87.10 / $112.20
| Professional | 26 | $60.26 | $87.10 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $162.18 / $204.17
| Professional | | $107.15 | $162.18 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $218.78 / $218.78
| Professional | | $177.83 | $218.78 | $218.78 |